A Guide

to Your

Benefits 2016

Understanding Annual

Enrollment

A Guide

to Your

Benefits 2018-2019

Understanding Annual

Enrollment

A GUIDE TO YOUR BENEFITS | 2018-2019

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Poquoson City Public Schools offers a comprehensive suite of benefits to promote health and financial security for you and your family. After a request for proposals and extensive and careful consideration of our group benefit options, the decision was made to continue to offer the current health plans through Anthem. Anthem medical changes are mentioned below.

The decision was also made to move the dental coverage to Anthem. The renewals and new plan year is October 1, 2018 through September 30, 2019.

WHAT IS NEW FOR THE 2018 - 2019 PLAN YEAR?

Prescription Drug Plan:

− POS HealthKeepers $20 / 20% Plan

• Change in prescription copayment per tier - $15 / $50 / $85 / 20% , $250 MAX

− Anthem Lumenos PPO High Deductible Health Plan (HDHP) $2,800 / 0% with option to open a Health Savings Account

• Change in prescription copayment per tier - $15 AD / $50 AD / $85 AD / 20% AD , $250 MAX (AD=After Deductible)

− Both Medical Plan options now include the ESSENTIAL Formulary for Prescriptions

• The Essential Drug List is a list of prescription medications approved by the U.S. Food and Drug Administration (FDA). Anthem has reviewed the drugs through their Pharmacy and Therapeutics (P&T) Process, which considers a drug’s effectiveness, safety, and similarity to drugs within a therapeutic class.

• Only the prescription drugs on the list will be covered by the plan. Drugs that aren’t covered have cost-effective, high-quality alternatives available. There may be a brand alternative, a generic equivalent or an over-the-counter (OTC) option. Brand-name drugs with a generic equivalent available aren’t covered on the Essential Drug List.

• There may be times when a member’s drug isn’t on the Essential Drug List and the doctor thinks that another option isn’t right for the member. The doctor can submit a request for prior authorization by calling the Member Services number on the member’s ID card or by going to anthem.com/ pharmacy information to download and submit the prior authorization form.

• For the most up-to-date information, please visit anthem.com/pharmacy information.

Dental **NEW CARRIER** - Anthem Dental

− Effective October 1, 2018, the new carrier will be Anthem Dental.

− Benefit and premium information can be found on page 7 of this guide.

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Benefit Basics As a full-time Poquoson City Public Schools employee, you are eligible for benefits.

You may enroll your eligible dependents for coverage once you are eligible. Your eligible dependents include:

Your legal spouse

Your children up to age 26

If your legal spouse is eligible for medical coverage where he or she is employed and you enroll them in your POS HealthKeepers plan, you will pay an additional $100 per month surcharge.

Once your benefit elections become effective, they remain in effect until the end of the plan year. You may only change coverage within 30 days of a qualified life event.

Qualified Life Events Generally you may change your benefit elections only during the open enrollment period. However, you may change your benefit elections during the year if you experience a qualified life event, including:

Marriage

Divorce

Birth of your child

Death of your spouse or dependent child

Adoption of or placement for adoption of your child

Change in employment status of employee, spouse or dependent child

Qualification by the Plan Administrator of a child support order for medical coverage

Entitlement to Medicare or Medicaid

Spouse’s open enrollment

You must notify Human Resources within 30 days of the qualified life event. Depending on the type of event, you may be asked to provide proof of the event. If you do not contact Human Resources within 30 days of the qualified life event, you will have to wait until the next open enrollment period to make changes (unless you experience another qualified life event).

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Medical Coverage The Poquoson City Public Schools health plans encourage overall well being through a series of generous benefits designed to promote wellness and healthy living. Poquoson City Public Schools offers employees the option to select the medical coverage that best meets their personal and family needs at varying price points of affordability.

For employees hired on or before June 30, 2017, there are two options for coverage through Anthem:

• KeyCare (HDHP) Lumenos $2,800 / 0%

• HealthKeepers (POS) $20 / 20%

For employees hired on or after July 1, 2017, there is one option for coverage through Anthem:

• KeyCare (HDHP) Lumenos $2,800 / 0%

Anthem has been providing insurance solutions for over 75 years and its vast networks offers a diverse range of health care professionals that provide quality and cost-effective care. You will have the option of choosing either a HealthKeepers or KeyCare network plan.

Point of Service Plan (POS)

Under the POS plan, you have the choice of selecting a Primary Care Physician (PCP ) to coordinate your care or you can coordinate your care yourself. A PCP is a doctor who specializes in family, general, internal or pediatric medicine. When coordinating care, you generally pay less out-of-pocket if you allow your PCP to coordinate your care and your services are received from an in-network provider. When utilizing non-participating providers you will have greater out-of-pocket expense. There are no referrals required.

Preferred Provider Organization (PPO)

Under the PPO plan, you have the choice of selecting a Primary Care Physician (PCP ) to coordinate your care or you can coordinate your care yourself. Coverage is available on a national basis and you may seek coverage from participating and non-participating providers. However, when you access care from participating providers, your out-of-pocket costs will be significantly less. There are no referrals required.

Qualified High Deductible Health Plan (HDHP)

A HDHP provides coverage after you meet the Plan’s deductible. Under the Plan, all expenses, except preventive care expenses, are subject to the plan’s deductible. This includes prescription drug coverage. With this coverage, you take control of how your healthcare dollars are spent. Poquoson City Public Schools has added a Preventive Rx rider that allows you to receive certain preventive prescription medication at no cost. See specific Anthem’s Preventive Rx Drug list for what is covered under the rider.

The HDHP does not require the designation of a primary care physician nor are referrals required; therefore, you make your own decisions about your doctors, your care and your costs. Further, coverage is available both in and out-of-network. By staying in-network, you take advantage of special rates and discounts that have been negotiated with participating doctors and facilities which means a higher level of reimbursement and less out-of-pocket cost to you and your family members.

Health Savings Account (HSA)

An HSA is a tax-advantaged health savings account whereby you can use funds to help pay for qualified health care related expenses, or save for the future. Unlike the Health Reimbursement Account (HRA) account that is employer owned, you may contribute funds to your HSA up to the annual contribution limit (with an additional catch-up contribution for participants age 55 and older) regardless of your HDHP annual deductible amount. Your contributions can be made on a pre-tax basis through payroll deduction or by direct contribution to the HSA Administrator (tax deduction obtained when you file your Federal tax return). Once you reach age 65 or over and enroll in Medicare Part A or B, you cannot continue to make contributions to an HSA; however, you can still make withdrawals.

The funds in your HSA are your money and there is no limit to the amount you can carry forward. Further, you own the account; therefore, if you leave employment with Poquoson City Public Schools the account and the money go with you.

Important Terms:

Deductible: You must first meet the in-network plan year deductible or the out-of-network maximum before Anthem will pay for any of your eligible covered services.

Coinsurance: The coinsurance is a percentage of the covered costs you pay after meeting the Plan’s deductible.

Out-of-Pocket Maximum: The Out-of-Pocket Maximum is the maximum that you would have to pay out-of-pocket for covered medical expenses in a plan year. Once you meet the Out-of-Pocket maximum, the plan pays 100% of covered eligible expenses for the remainder of the year.

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Medical Coverage Overview - Anthem

4

HealthKeepers Network KeyCare Network

POS HealthKeepers$20 / 20% (Employee Pays)

Lumenos HDHP/HSA $2,800 / 0% (Employee Pays)

Plan Provisions In-Network In-Network

Plan Year Deductible (Individual / Family) $0 / $0 $2,800 / $5,600

Out-of-Pocket Maximum (Includes Deductibles and Copayments) $4,000 / $8,000 $4,000 / $8,000

Coinsurance 20% 0%

Lifetime Maximum Unlimited Unlimited

Preventive Care Services No charge No charge

Primary Care Physician / Specialist Office Visit $20 / $40 0% AD

Diagnostic X-Ray and Lab 20% office/$300 outpatient hospital 0% AD

Advanced Diagnostic Imaging (CT, MRI, PET) 20% / $300 0% AD

Inpatient Hospital Services $300 per day up to 5 days

& $40 doctor copay 0% AD

Outpatient Hospital Services $300 per visit & $40 doctor copay 0% AD

Urgent Care $40 0% AD

Emergency Room Care $250 0% AD

Prescription Drug Coverage $15 / $50 / $85 / 20% $250 MAX $15AD / $50AD / $85AD / 20% AD

$250 MAX

Prescription Drug Preventive Rider Not applicable $0

What Expenses are not Subject to the Deductible? Under the Lumenos HDHP Plan, all expenses, except preventive care expenses and Preventive Rx medications, are subject to the plan’s deductible. This includes prescription drug coverage that is not part of the Preventive Rx plan. An overview of the types of Preventive care expenses that are NOT subject to the Plan’s deductible and that are paid 100% by the Plan, include:

Child Preventive Care Services Adult Preventive Care Services

Office Visits for preventive services Screening Tests for vision, hearing, and lead exposure. Also

includes pelvic exam and Pap test for females who are age 18, or have been sexually active.

Immunizations

Office Visits for preventive services Screening Tests for coronary artery disease, colorectal cancer,

prostate cancer, diabetes, and osteoporosis. Also includes mammograms, as well as pelvic exams and Pap test.

Immunizations

AD = AFTER DEDUCTIBLE NOTE: All plans above include out-of-network coverage. Please see Anthem’s Certificate of Coverage for full details. Doctors/Hospitals out-of-network are not obligated to perform pre-authorization or accept Anthem’s allowance. They may balance bill the difference between the allowance and their charges; that difference DOES NOT accumulate to deductible or out of pocket noted above.

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HDHP & HSA Working Together

Who Can Establish and Contribute to an HSA?

To be eligible, an individual:

Must be covered under a qualified HDHP on the first day of any month for which eligibility is claimed.

May not be covered under any health plan (including TRICARE, a general purpose flexible spending account (FSA) or spouse’s FSA, health benefits or prescription drugs received from the Veterans Administration or one of its facilities in the last three months or Social Security Disability Insurance) that is not a qualified HDHP.

Must not be enrolled in Medicare.

May not be claimed as a dependent on another individual’s tax return.

Making Contributions to Your HSA

For 2018, the annual HSA contribution limit is:

$3,450 for single coverage

$6,900 for family coverage

If you are age 55 or older, you may make an additional “catch-up” contribution of $1,000.

Anyone (you, employer, family member, or any other person) may contribute to your HSA.

Contributions to Your HSA

To help employees get started building their HSA fund and to help cover expenses subject to the Plan’s deductible, Poquoson City Public Schools will make a contribution to each employee who enrolls in the HDHP and opens an HSA account. See charts on right for details and contribution amounts.

The contributions will be made on the effective date of the new plan year or when you become eligible for coverage.

Health Savings Account Administrator

Poquoson City Public Schools has partnered with Benefit Wallet to provide the administrative services for employees’ HSA accounts.

Employees opening an HSA can choose which type of account they prefer. Your options are:

Cash Account (default account) – an interest bearing account which includes a debit card. Minimum threshold of $1,000 must be maintained in the Cash Account before funds can be transferred to the Mutual Funds.

Mutual Funds – Variety of Mutual Fund options.

The Bank of New York Mellon (BNY Mellon) is the custodian of the FDIC-insured portion of the Benefit Wallet HSA. The HSA administration fee is covered in the premium. The maintenance fees associated with the investment options are withdrawn directly from your account.

In order to sign up for an HSA, employees must first enroll in the Lumenos HDHP plan. Next, complete the Benefit Wallet Enrollment Form.

For more information or to access your HSA account, please visit www.mybenefitwallet.com. Or you can call customer service at (877) 472-4200.

Examples of Qualified HSA Expenses

Medical, dental, and vision deductibles,

copayments and coinsurance amounts

Long Term Care insurance premiums

COBRA continuation premiums

Medicare premiums

Important Information About HSA’s

HSAs provide triple-tax savings:

Contributions to the HSA are tax-free

Your account and investment earnings are tax-free

You can withdraw your money tax-free at any time, as long as you use it for qualified medical expenses

Contributions to an HSA are based on a calendar year.

Funds must be accrued in the account before they can be used for reimbursement.

HSA owners must file Form 8889 with their individual tax return.

HSA Facts

Money in the account belongs to you. Account balance is portable upon retirement or

termination from the Poquoson City Public Schools.

Funds earn tax-free interest or investment return. Pay for qualified medical expenses with tax-free

dollars. Funds not used for qualified expenses are subject

to an additional 20% tax.

Coverage Initial /

One-Time Annual Starting

Year Two

Employee Only $600 $200

Employee Plus 1 Child $900 $300

Employee Plus Children $1,200 $400

Employee Plus Spouse $1,200 $400

Employee Plus Family $1,200 $400

PCPS Health Savings Account Contribution

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Under health care reform, you can get certain FDA-approved

prescription drugs and many over-the-counter (OTC) products

to help you quit tobacco use and it won’t cost you anything

extra!

Here’s all you have to do:

1. Ask your doctor if one or more of the covered prescription

drugs and/or OTC products would be good for you. If so,

you will need to get a prescription for each one. (Yes, even

OTC products will need a prescription.)

2. Go to the pharmacy that’s in your health plan’s network to

fill your prescription.

3. Show the pharmacist proof that you’re at least 18 years

of age.

Sampling of Covered prescriptions and OTC products:

• Chantix

• Buproban

• Bupropion SR (generic Zyban)

• Nicotine Gum (see covered list)

• Nicotine lozenge (see covered list)

• Nicotine transdermal patch (see covered list)

Get even more support at www.anthem.com. Log on and click

on the Health and Wellness section for resources, videos and

even an online community for information and inspiration to

help you quit!

Embedded Deductible

If you are on a family (two or more dependents covered) medical plan with an embedded deductible, your plan contains two components, an individual deductible and a family deductible. Having two components to the deductible allows each member of your family the opportunity to get her medical bills covered prior to the entire dollar amount of the family deductible being met. The individual deductible is embedded in the family deductible.

Embedded Example

For example, if you, your wife and daughter are on a family plan with a $5,600 family embedded deductible, including an individual deductible of $2,800, and your daughter incurs $2,800 in medical bills, her deductible is met and your insurance will help pay any subsequent medical bills for your daughter that year even though the family deductible of $5,600 has not yet been met.

Ready to Quit Smoking or Using Tobacco Products?

Questions about how to use LiveHealth Online? Call toll free at 1-888-LiveHealth (548-3432) or email help@livehealthonline.com. If you send an email, please include your name, email address and a phone number where we can reach you.

The cost for a consultation, which you can pay by debit or credit card is: • $10 - POS HealthKeepers Plan • 0% after deductible * Lumenos

HDHP/ HSA Plan (*$49 for medical services before your deductible is met)

LiveHealth Online Visit a doctor without going to a doctor's office Sometimes you just need a doctor – whether you’re at home in the middle of the night or in the middle of a road trip. Now you can talk to a doctor any time of day, wherever you are. LiveHealth Online lets you have face-to-face conversations with a doctor on your computer or mobile device with 24/7 access. It’s medical advice the moment you need it. No appointments. No waiting. So simple. And it costs less than you would pay for a regular doctor visit. Sign up today so you can get the care you need in minutes! Download the LiveHealth app or go to livehealthonline.com

*Some of these conditions may require additional in person evaluation **Prescription availability is defined by physician judgment and state regulations. ***Note: Allowable fees vary for the therapy/psychology services under the Lumenos HDHP.

When can you use LiveHealth Online? You can use LiveHealth Online whenever you have a health concern and don’t want to wait. Doctors are available 24 hours a day, seven days a week, 365 days a year. Some of the most common uses include:

Abrasions, minor wounds, sprains and strains Acne, rashes, allergies/allergic rhinitis Asthma/cough/cold/sore throat/pharyngitis Back pain

Pinkeye and other eye infections Ear pain/Headache/migraine Hypertension

Influenza/flu/fever/sinus infection, UTI

Insomnia

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Costs for Coverage

Medical – Monthly Cost for Coverage

Dental – Monthly Cost for Coverage

Plan Employee Only

Dual

(Employee Plus One Child or

Employee Plus Spouse)

Family

Anthem Dental $40.37 $67.79 $107.85

Plan Employee Only Employee +

Child

Employee +

Children

Employee +

Spouse Family

Lumenos HDHP/ HSA

$2,800 / 0% ** $0.00 $164.00 $169.00 $194.00 $358.00

POS HealthKeepers $20 / 20% * $21.50 $231.00 $236.00 $282.50 $469.00

*If you are enrolled in the POS HealthKeepers plan and cover your spouse, you will be required to complete a Spousal Affidavit. If your spouse has eligible coverage through his/her employer, you will pay a spousal surcharge of $100 per month.

**If enrolled in HDHP, you may be eligible for contribution to a HSA. See page 5 for HSA eligibility requirements and page 1 for contribution amounts.

This benefit summary provides selected highlights of the Poquoson City Public Schools employee benefits program. It is not a legal document and shall not be construed as a guarantee of benefits. All benefit plans are governed by master policies, contracts and plan documents. Any discrepancies between any information provided through this summary and the actual terms of the policies, contracts and plan documents are governed by the terms of these policies, contracts and plan documents. Poquoson City Public Schools reserves the right to amend, suspend or terminate any benefit plan, in whole or in part, at any time. The Plan Administrator has the authority to make these changes.

Anthem Dental Coverage – ***NEW CARRIER** Regular dental exams can help you and your dentist detect problems in the early stages when treatment is simpler and costs are lower. Keeping your teeth and gums clean and healthy will help prevent most tooth decay and periodontal disease, and is an important part of maintaining your medical health.

Register at www.anthem.com to access a personalized self-service site for members to access benefit plan information, claim status, EOB history and locate a network provider.

Plan Provision

In-Network (Employee Pays)

Out-of-Network (Employee Pays)

Plan Year Deductible (Individual / Family)

$50 / $150 $50 / $150

Annual Maximum (per person)

$2,000

Orthodontic Maximum $1,500

Diagnostic and Preventive Care

100%, no deductible 100%, no deductible

Basic Services 80% after deductible 80% after deductible

Major Services 50% after deductible 50% after deductible

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Benefits Available through First Financial Group of America Medical flexible spending accounts

Dependent care flexible spending accounts

Supplemental retirement plans

Separate insurance plans for vision, disability, life, accident, cancer, heart/stroke, critical illness, hospital protection, and long term care.

For more information regarding these benefits, please visit http://benefits.ffga.com/poquosoncitypublicschools. You may also contact First Financial Group of America’s Customer Service toll-free at (800) 924-3539.

Flexible Spending Accounts (FSA) Poquoson City Public Schools will continue to offer employees the opportunity to set aside money in a reimbursement account before taxes are deducted to pay for certain health and dependent care expenses. This lowers your taxable income and increases your take home pay. Only expenses for services incurred during the plan year while you are actively employed are eligible for reimbursement from your accounts. The plan is administered by First Financial Group of America. You must re-enroll in the FSA plan(s) every year.

If you and/or your spouse are enrolled in the KeyCare HDHP/HSA and have opened a Health Savings Account (HSA), IRS regulations do not allow you to contribute to a general purpose Medical Flexible Spending Account.

Medical Flexible Spending Account

Helps you pay for medical, dental, and vision expenses that are not covered or fully reimbursed by your other benefit plans (for example, copays, coinsurance amounts, and amounts above benefit maximums) as well as over-the-counter, medically necessary items. Over-the-counter medications are not eligible unless you have a letter of medical necessity or prescription from your doctor.

The maximum amount you can contribute to your Medical Flexible Spending Account is $2,600 per plan year.

Dependent Care Flexible Spending Account

Reimburses you for eligible dependent care expenses (day care and elder care) that enable you and your spouse, if you are married, to work.

The maximum amount you can contribute to the Dependent Care Flexible Spending Account is $5,000 if you are a single employee or married filing jointly, or $2,500 if you are married and filing separately.

Employee Assistance Program (EAP) – Optima EAP Poquoson City Public Schools offers an Employee Assistance Program (EAP) at no cost to you. It is available for you and your household members. You do not have to be enrolled in the medical plan in order to take advantage of the EAP. When you find yourself in need of some professional support to deal with personal, work, financial or family issues, the Employee Assistance Program (EAP) can assist. You and your household members are eligible for up to 5 visits for each personal situation, as needed. Some of the various topics as part of the program include:

To contact Optima EAP, call toll-free at (800) 899-8174 or go online: www.OptimaEAP.com .

Relationships Grief/Loss

Work-related concerns Anger Management

Stress, anxiety, and depression Personal development

Children/Adolescents Substance abuse

Eldercare

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Legal Resources of Virginia

Poquoson City Public Schools will continue to offer employees the opportunity to enroll in an employee legal plan through Legal Resources of Virginia. The Legal Resources Comprehensive Legal Plan provides 100% coverage for you, your spouse and qualifying dependent children for a broad range of legal services, protecting you and your family from the high cost of attorney fees. Coverage is provided for many common legal needs, such as:

The monthly premium for covered services is $18.50 through payroll deduction. Other legal services might be available for an additional cost directly through Legal Resources of Virginia. For more information, contact Legal Resources of Virginia toll-free at (800) 728-5768 or online at www.LegalResources.com.

Optional Group Life Insurance Program

If you are covered under the Virginia Retirement System Group Life Program, you may purchase additional coverage for yourself through the Optional Group Life Insurance Program through Minnesota Life. If you elect optional group life insurance coverage, you may also cover your spouse and dependent children. Optional group life insurance provides benefits for natural and accidental death or dismemberment. You pay the premiums through payroll deduction.

If you enroll in the Optional Group Life Insurance Program within 31 days of your employment date or a qualifying life event, you are not required to provide evidence of insurability. However, you will be required to provide evidence of insurability if you apply and/or wish to add your spouse or dependent children after 31 days from your employment date or qualifying life event, you wish to purchase more than $375,000 in coverage for yourself, you wish to increase your coverage, or your spouse’s insurance amount is more than half your salary.

For more information please visit http://varetire.org/members/benefits/life-insurance/index.asp or contact Minnesota Life toll-free at (800) 441-2258.

Commonwealth of Virginia 457 Deferred Compensation Plan

Poquoson City Public Schools participates in the Commonwealth of Virginia’s 457 Deferred Compensation Plan. This plan allows you to save for retirement on a tax-deferred basis through convenient payroll deductions. Your contributions and any earnings are tax-deferred.

There are two types of contributions you may make to your Commonwealth of Virginia 457 Plan:

Pre-tax contributions – you pay taxes on these contributions later, which lowers your taxable income now.

Roth (after-tax) contributions – you pay taxes on these contributions now and make tax-free withdrawals later, as long as certain criteria are met. (Virginia Retirement System Hybrid members are not eligible to make Roth contributions.)

The plan offers a variety of investment options. You do not have to take your money out of the Commonwealth’s 457 Deferred Compensation Plan when you retire or terminate employment. You can leave your money in the plan until you are age 70 ½, when you may be required to take minimum distributions.

Eligible participants that wish to enroll in this plan can visit http://www.varetirement.org/dcp.html for more information. You may also call toll-free at (877) 327-5261.

Legal advice and consultation Family law

Wills and estate planning Traffic violations

Purchase, sale or refinance primary residence

Civil actions

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Important Notices

10

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2018. Contact your State for more information on eligibility –

ALABAMA – Medicaid FLORIDA – Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: http://dch.georgia.gov/medicaid - Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507

ARKANSAS – Medicaid INDIANA – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864

COLORADO – Health First Colorado (Colorado’s Medicaid Program) &

Child Health Plan Plus (CHP+)

IOWA – Medicaid

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711

Website: http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp Phone: 1-888-346-9562

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Important Notices

11

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

Website: https://www.dhhs.nh.gov/ombp/nhhpp/ Phone: 603-271-5218 Hotline: NH Medicaid Service Center at 1-888-901-4999

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

LOUISIANA – Medicaid NEW YORK – Medicaid

Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

Website: https://dma.ncdhhs.gov/ Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid

Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP

Website: http://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/medical-assistance.jsp Phone: 1-800-657-3739

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

MISSOURI – Medicaid OREGON – Medicaid

Website: https://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

MONTANA – Medicaid PENNSYLVANIA – Medicaid

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

Website: http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htm Phone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – Medicaid

Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178

Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347

NEVADA – Medicaid SOUTH CAROLINA – Medicaid

Medicaid Website: https://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

Website: https://www.scdhhs.gov Phone: 1-888-549-0820

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Important Notices

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To see if any other states have added a premium assistance program since January 31, 2018, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services

www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 12/31/2019)

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid

Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – Medicaid

Website: http://gethipptexas.com/ Phone: 1-800-440-0493

Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP

Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid

Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP

Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282

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Important Notices

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Health Information Privacy Practices

Anthem (the “Plan”) provides health benefits to eligible employees of Poquoson City Public Schools and their eligible dependents as described in the summary plan description for the Plan. The Plan creates, receives, uses, maintains and discloses health information about participating employees and dependents in the course of providing these health benefits.

The plan is required by law to provide notice to participants of the Plan’s duties and privacy practices with respect to covered individual’s protected health information, and has done so by providing to Plan participants a Notice of Privacy Practices, which describes the ways the Plan uses and discloses PHI. To receive a copy of the Plan’s Notice of Privacy Practices you should contact Anthem’s customer service on your ID card for all issues regarding the Plan’s privacy practices and covered individual’s privacy rights.

HIPAA Special Enrollment Rights

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself or your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

Special enrollment rights also may exist in the following circumstances:

If you or your dependents experience a loss of eligibility for Medicaid or a state Children’s Health Insurance Program (CHIP) coverage and you request enrollment within 60 days after that coverage ends; or

If you or your dependents become eligible for a state premium assistance subsidy through Medicaid or a state CHIP with respect to coverage under this plan and you request enrollment within 60 days after the determination of eligibility for such assistance.

Note: The 60-day period for requesting enrollment applies only in these last two listed circumstances relating to Medicaid and state CHIP. As described above, a 30-day period applies to most special enrollments.

To request special enrollment or obtain more information, contact Human Resources.

Patient Protection Model Disclosure

Anthem generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. If the plan or health insurance coverage designates a primary care provider automatically, until you make this designation, Anthem designates one for you. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact Anthem at the customer service number on your ID card.

For children, you may designate a pediatrician as the primary care provider.

You do not need prior authorization from Anthem plans or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the Customer Service number on your Anthem ID card.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

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Medicare Part D Creditable Coverage Notice Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Poquoson City Public Schools and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. Poquoson City Public Schools has determined that the prescription drug coverage offered by Anthem is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current Poquoson City Public Schools coverage may be affected.

Poquoson City Public Schools Plan, administered by Anthem, effective October 1, 2018:

PPO KeyCare HDHP/HSA $2,800 / 0% POS HealthKeepers $20 / 20%

Tier 1: Member pays a $15 copayment after deductible Tier 1: Member pays a $15 copayment

Tier 2: Member pays a $50 copayment after deductible Tier 2: Member pays a $50 copayment

Tier 3: Member pays a $85 copayment after deductible Tier 3: Member pays a $85 copayment

Tier 4: Member pays 20% after deductible Tier 4: Member pays 20%

If you do decide to join a Medicare drug plan and drop your current Poquoson City Public Schools coverage, be aware that you and your dependents will not be able to get this coverage back.

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The Women’s Health and Cancer Rights Act of 1998 The Women’s Health and Cancer Rights Act of 1998 requires group health plans to make certain benefits available to participants who have undergone a mastectomy. In particular, a plan must offer mastectomy patients benefits for:

All stages of reconstruction of the breast on which the mastectomy was performed

Surgery and reconstruction of the other breast to produce a symmetrical appearance

Prostheses

Treatment of physical complications of the mastectomy, including lymphedema

Our plan complies with these requirements. Benefits for these items generally are comparable to those provided under our plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a matter to be determined by the patient and her physician. Our plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements. If you would like more information about WHCRA required coverage, you may contact Human Resources.

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When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with Poquoson City Public Schools and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage…

Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Poquoson City Public Schools changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:

Visit www.medicare.gov.

Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help.

Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Date: October 1, 2018

Name of Entity/Sender: Poquoson City Public Schools

Contact|Position/Office: Human Resources

Address: 500 City Hall Avenue

Poquoson, VA 23662

Phone: (757) 868-3055

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Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable

coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).